Cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme compared with usual care using a CBT manual alone for patients with heart failure: secondary analysis of data from the SEMAPHFOR trial.

OBJECTIVE: To assess the cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme for patients with heart failure compared with usual care including the un-facilitated access to the same manual, from the perspective of the NHS. DESIGN: Data were obtained from a pragmatic, multi-centre, randomized controlled 'open' trial conducted in seven centres in the UK between 2006 and 2008. Effectiveness was estimated as Quality-Adjusted Life Years. Resource use was measured prospectively on all patients using information provided by patients in postal questionnaires, case-note review, electronic record review and interviews with patients. Unit costs were obtained from the literature and applied to the relevant resource use to estimate total costs. Multiple imputation was used to handle missing data. RESULTS: There were no substantial differences in the utility scores between treatment groups in all follow-up assessments, in the use of medication or outpatient visits and both groups report a similar frequency of contact with health care professionals. After controlling for baseline utility and using imputed dataset, treatment was associated with a reduction in QALY of 0.004 and a additional cost of £69.49. The probability that the intervention is cost-effective for thresholds between £20,000 and £30,000 is around 45%. CONCLUSIONS: There is little evidence that the addition of the intervention had any effect on costs or outcomes. The uncertainty around both estimates of cost and effectiveness mean that it is not reasonable to make recommendations based on cost-effectiveness alone.

Nurse facilitated Self-management support for people with heart failure and their family carers (SEMAPHFOR): a randomised controlled trial.

OBJECTIVE: To compare the clinical effectiveness of a newly developed cognitive behavioural self-management manual delivered by specialist heart failure nurses or the same programme followed by the patient on their own, in terms of readmissions/admissions to hospital for any reason within a 12 month period, patient health related quality of life, self-management and carer quality of life. DESIGN: Pragmatic, open parallel group, randomised controlled trial. SETTING: Open access heart failure diagnostic clinics and primary care. PARTICIPANTS: 260 patients with a definitive diagnosis of symptomatic heart failure (LVSD) as defined by ECHO, clinical diagnosis or coronary angiography were eligible for the study. INTERVENTION: A newly developed nurse facilitated, cognitive behavioural self-management programme was developed and was delivered either by a heart failure nurse or by the patient on their own. MAIN OUTCOME MEASURES: Patient admission/readmission to hospital for any reason within a 12 month period following randomisation. Secondary outcomes were: participant health related quality of life as measured by the Minnesota Living with Heart Failure questionnaire, the Hospital, Anxiety and Depression Scale, the European self-care form. RESULTS: There was no evidence of a difference between the groups in whether or not a patient was re-admitted to hospital during the 12 month follow-up period (p=0.66). There was no evidence of a difference between the treatment groups in the mean MLHF scores over time (p=0.768), the European self-care questionnaire (p=0.340) or the mean HAD anxiety score (p=0.786). However, when adjusted for baseline scores the self-management group had a statistically significant higher HADS depression score at 12 months (p=0.003). CONCLUSION: There was no evidence of a difference in admissions/readmission to hospital between patients who undertook a brief heart failure self-management programme facilitated by a specialist heart failure nurse and those also receiving care from a specialist nurse who followed the programme on their own. TRIAL REGISTRATION: This trial is registered as ISRCTN84692046.

Collaborative palliative care for advanced heart failure: outcomes and costs from the 'Better Together' pilot study.

BACKGROUND: Patients with heart failure often receive little supportive or palliative care. 'Better Together' was a 2-year pilot study of a palliative care service for patients with advanced congestive heart failure (CHF). OBJECTIVE: To determine if the intervention made it more likely that patients would be cared for and die in their place of choice, and to investigate its cost-effectiveness. METHODS: This pragmatic non-randomised pilot evaluation was set in two English primary care trusts (Bradford and Poole). Prospective patient-level data on outcomes and costs were compared with data from a historical control group of clinically comparable patients. Outcomes included death in preferred place of care (available only for the intervention group) and 'hospital admissions averted'. Costs included medical procedures, inpatient care and the direct cost of providing the intervention. RESULTS: 99 patients were referred. Median survival from referral was 48 days in Bradford and 31 days in Poole. Most patients who died did so in their preferred place of death (Bradford 70%, Poole 77%). An estimated 14 and 18 hospital admissions for heart failure were averted in Bradford and Poole, respectively. The average cost-per-heart failure admission averted was £1529 in Bradford, but the intervention was cost saving in Poole. However, there was considerable uncertainty around these cost-effectiveness estimates. CONCLUSIONS: This pilot study provides tentative evidence that a collaborative home-based palliative care service for patients with advanced CHF may increase the likelihood of death in place of choice and reduce inpatient admissions. These findings require confirmation using a more robust methodological framework.

Palliative care in advanced heart failure: an international review of the perspectives of recipients and health professionals on care provision.

BACKGROUND: People with advanced heart failure (HF) have demonstrable supportive and palliative care needs. Effective service configuration and delivery should be informed by the views of those with personal experience and knowledge and should be based on available evidence. This systematic literature review aimed to collate qualitative and quantitative evidence on: 1) patients' perceived needs and experiences of care provision; and 2) the perspectives and understanding of health professionals on care delivery. METHODS AND RESULTS: A systematic literature search using Medline, Embase, Cinahl, Psycinfo, and Amed identified 48 relevant studies. Data extraction and quality evaluation for included studies were conducted by 2 independent reviewers. Findings were grouped according to themes generated from the qualitative studies. Key findings were that advanced HF patients report little discussion with health professionals about their clinical status and sense a lack of timely support to accommodate their evolving needs. Health professionals report poor multidisciplinary communication and lack confidence both in diagnosing advanced HF and in communicating a poor prognosis to those affected, affecting the provision of good-quality coordinated care. CONCLUSIONS: This review demonstrates the need for improvement in coordination of care and communication between patients, their families, and health care professionals. However, although there is broad agreement between the disciplines of cardiology and palliative care regarding the provision of therapies to reduce symptoms, improve function, and enhance quality of life, differences in views may arise, particularly regarding the maintenance of life-prolonging treatment as goals of care change.

The decision making of heart failure specialist nurses in clinical practice.

AIMS AND OBJECTIVES: To explore decision processes and types of decisions made by heart failure specialist nurses. BACKGROUND: Heart failure specialist nurses are key to the management of patients with heart failure in the community. In previous studies heart failure specialist nurses have reported difficulty in developing decision making skills. Cognitive continuum theory can be used to examine the relationship between decision tasks and the processes used by heart failure specialist nurses to make decisions. DESIGN: A qualitative study using non-participant observation and semi-structured interviews. METHODS: Six heart failure specialist nurses were observed while they carried out consultations with three patients each (n = 18). Twelve heart failure specialist nurses were interviewed about their decision making in practice. Data were analysed using thematic content analysis. RESULTS: Two areas of decision making were identified by heart failure specialist nurses as key; pharmacological management and managing patients in the palliative phase of their condition. Pharmacological management decisions involved the trading off of risks and benefits of titrating medication, with nurses using internalised guidelines to inform their practice. In contrast, nurses relied on support from other health care professionals when making decisions about a patient's need for palliative care. CONCLUSIONS: Medication titration decisions have a mixture of intuition and analysis inducing features making them amenable to the use of decision tools. The timing of the need for palliative care is less predictable, suggesting an intuitive approach to decision making may be more appropriate. RELEVANCE TO CLINICAL PRACTICE: There are several strategies that could be used to improve the match between the decisions that heart failure specialist nurses take and the decision processes they use. These include the development of more tailored decision support tools for medication titration decisions and the provision of structured decision aids for assessing patients' need for palliative care.

Do heart failure specialist nurses think differently when faced with 'hard' or 'easy' decisions: a judgement analysis.

AIMS: To unpack specialist heart failure nurses' decision-making and explore whether viewing a decision as 'hard' or 'easier' is associated with different decision-making characteristics. BACKGROUND: Specialist heart failure nurses exemplify modern nursing roles. They face diagnostic, prognostic and treatment uncertainties of varying degrees of complexity in the choices they face. Nurses' cognitive handling of complexity is largely unknown. DESIGN: Judgement analysis survey. METHODS: Judgement analysis with 29 nurses and two judgement tasks was undertaken. A drug titration decision (classed as 'easier' by nurses) was compared with a 'harder' palliative care referral choice. Measures of agreement between the nurses, the linearity and non-linearity in information processing by nurses and the degree of cognitive control exercised by them were explored. Differences between nurses with varying degrees of education were explored using paired t-testing. The relationship between experience and key measures was explored using bivariate correlations. RESULTS: Nurses varied in their judgements and the weighting afforded to information. Self-reported decision difficulty was less important for cognitive handling of information and agreement between nurses than we predicted. Nurses had high degrees of cognitive control in the drug task and far less in the palliative referral condition. However, there was no change in the linear or non-linear processing of information of the two tasks. Education and clinical experience were not related to agreement or information processing. CONCLUSIONS: Nurses' self-reported difficulty in decisions should not be relied upon as valid indicators of decisional complexity. The title 'specialist nurse' should not be assumed to equate by default with clinical expertise. Thinking in a more sophisticated way about the relationship between experience, uncertainty, decision structure and information available may help nurses make better choices. RELEVANCE TO CLINICAL PRACTICE: Teaching nurses about what makes for hard and difficult decisions and increasing awareness of the decisions they make may lead to better quality choices. Practice developers should pay attention to the quality of clinical experience as well as the quantity when considering decision-making expertise.

Systematic review of the effectiveness of stage based interventions to promote smoking cessation.

OBJECTIVE: To evaluate the effectiveness of interventions using a stage based approach in bringing about positive changes in smoking behaviour. DESIGN: Systematic review. DATA SOURCES: 35 electronic databases, catalogues, and internet resources (from inception to July 2002). Bibliographies of retrieved references were scanned for other relevant publications, and authors were contacted if necessary. RESULTS: 23 randomised controlled trials were reviewed; two reported details of an economic evaluation. Eight trials reported effects in favour of stage based interventions, three trials showed mixed results, and 12 trials found no statistically significant differences between a stage based intervention and a non-stage based intervention or no intervention. Eleven trials compared a stage based intervention with a non-stage based intervention, and one reported statistically significant effects in favour of the stage based intervention. Two studies reported mixed effects, and eight trials reported no statistically significant differences between groups. The methodological quality of the trials was mixed, and few reported any validation of the instrument used to assess participants' stage of change. Overall, the evidence suggests that stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour. CONCLUSIONS: Limited evidence exists for the effectiveness of stage based interventions in changing smoking behaviour.

Decision making processes in people with symptoms of acute myocardial infarction: qualitative study.

OBJECTIVE: To identify the themes that influence decision making processes used by patients with symptoms of acute myocardial infarction. DESIGN: Qualitative study using semistructured interviews. SETTING: Two district hospitals in North Yorkshire. PARTICIPANTS: 22 patients admitted to hospital with confirmed second, third, or fourth acute myocardial infarction. MAIN OUTCOME MEASUREMENTS: Patients' perceptions of their experience between the onset of symptoms and the decision to seek medical help. RESULTS: Six main themes that influence the decision making process were identified: appraisal of symptoms, perceived risk, previous experience, psychological and emotional factors, use of the NHS, and context of the event. CONCLUSIONS: Knowledge of symptoms may not be enough to promote prompt action in the event of an acute myocardial infarction. Cognitive and emotional processes, individual beliefs and values, and the influence of the context of the event should also be considered in individual interventions designed to reduce delay in the event of symptoms of acute myocardial infarction.